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September 16th, 2010
09:34 AM ET

What makes a good doctor? Can we measure it?

Everybody wants quality health care. Who can argue with that? But it’s not so easy to measure “quality’ in medicine in an accurate and meaningful way.

Physician report cards are a big part of the quality movement, and they have generated a lot of controversy. As a primary care doctor, I receive a regular report card on my patients with diabetes. The problem is, these reports usually measure only what is easy to measure—small details taken in isolation that don’t capture the totality of complex medical care. Yet this is what we are graded on.

When I wrote a recent essay in the New England Journal of Medicine about how dispiriting these report cards are, I was besieged with negative blogosphere commentary about how doctors are afraid to be rated like everyone else. Many of these commentators, interestingly, were doctors who were not practicing clinicians.

My inbox, though, was flooded with personal letters from doctors and nurses struggling to give good-quality, humane medical care in an impossibly complicated system. For these caregivers, the report cards sap what little morale they have left, and offer nothing in the way of helping them with their patients.

A new study in JAMA sheds more light on the limitations of our current quality measures. Data were gathered on more than 125,000 patients receiving care from primary-care internists. Doctor who cared for patients with significant challenges (underinsured, minority, poor socioeconomic status, non-English speaking) ranked lower in quality measures than doctors who cared for wealthier, educated, insured patients.

Does this mean that it’s only the lousiest of doctors who choose to work with underserved patients? Or does it mean that these quality measures might be affected by systemic, societal factors that are beyond the control of individual doctors?

I believe that it is the latter. I confess that I am biased, since I work in an urban clinic with an underserved population. My colleagues are superb, committed doctors in whom I’d trust the medical care of my family in a heartbeat.

But beyond my own instinct, I think the data support that our current “quality measures” do not necessarily reflect who is a good doctor and who is a lousy doctor. When the researchers in the JAMA study controlled for these extrinsic societal factors, more than a third of the doctors’ rankings were adjusted upward.

Either these lousy doctors suddenly became better doctors, or our current method of rating them does not (at least yet) accurately measure quality of care.

Danielle Ofri is associate professor of medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. Her most recent book, “Medicine in Translation: Journeys with My Patients.” is about the care of immigrants and Americans in the U.S. health care system.


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soundoff (34 Responses)
  1. sringangel

    I believe the reason for such difference between underserved populations and wealthy ones are due to the services being practiced by different how should I say it, rank of doctors, in the sense, most underserved populations are treated by trainees and houseman while the wealthy's of course prefer going to private hospitals which offer more experience doctors in service. So the bias in this study shows.

    September 16, 2010 at 10:37 | Report abuse | Reply
  2. E King

    Compassion. That makes a good doctor. A good sense of humour also helps. I have found the least compassion amongst surgeons. As a patient, I have found only arrogance and rudeness from them. One surgeon told me – verbatim "You're a pain in the ass" – for complaining to the nurse about the NG tube discomfort. Another told me I was a "complications magnet" and he didn't want to ever do surgery on me again. This adds insult to injury. I am terrified now of ever having surgery again and I have chronic SBO problems – as well as adhesive dis. Very disheartening.

    September 16, 2010 at 10:40 | Report abuse | Reply
    • Kay

      I agree. When my mother was terminally ill, the doctor who had the least compassion was the surgeon. Maybe being a surgeon attracts a cold personality type, because the patient is usually under general anesthesia and they don't have to interact as much as other doctors.

      September 16, 2010 at 11:59 | Report abuse |
    • RadTech01

      Kay, I believe surgeons are so cold b/c they can be. No one brings it to their attention about how much of an a s s they are being b/c they saved someone's life or they mended their broken leg. In essence, these people play God and it gets in their head. I'm not saying that it wouldn't happen to me, but it would be nice if they were a little more compassionate.

      September 16, 2010 at 14:41 | Report abuse |
    • John

      Amen, Not to mention. How about LISTENING instead of just HEARING your patiens. Listening means actually processing what you said and responding accordingly. It is very irritating when they give you time to talk and then go on with their spiel of what they want to perscribe you (60s Drug pusher style) and completely dismiss whatever you say. Their pat answer if you sound concerned is "Well the studies say". Need we forget that over 90% of those studies are funded by the very people (Drug companies) who want to sell medication and make HUGE profits. They pay off the FDA, who does receive alot of funding from drug companies, to pass drugs and then sell as much as possible before they get recalled. How many of you are tired of drug companies advertising on TV, just so the uninformed consumer will suggest a medication possibility? Isn't that what the doctors are supposed to know?

      September 16, 2010 at 15:50 | Report abuse |
    • Nicole24

      I think it's ridiculous you guys are willing to put down a WHOLE field of doctors due to your experience. I have never had a bad experience from any of my surgeons, and I am even more grateful for that when I realize that they are all overworked and suffer from general lack of sleep. There is no excuse to act like a jerk, but blatantly disregarding the thousands of great surgeons out there due to one experience makes me question your characters.

      September 16, 2010 at 16:06 | Report abuse |
    • Joanne

      Compassion is def #1 quality. Then listening and communication. America needs to fix the pay equity problem in the medical field so our family practice doctors are paid as much as our surgeons.

      February 8, 2011 at 00:02 | Report abuse |
  3. sringangel

    I believe the reason for such difference between underserved populations and wealthy ones are due to the services being practiced by different how should I say it, rank of doctors, in the sense, most underserved populations are treated by trainees and houseman while the wealthy's of course prefer going to private hospitals which offer more experience doctors in service. Therefore the bias in this study shows.

    September 16, 2010 at 10:40 | Report abuse | Reply
  4. mabel floyd

    when i go to the hospital my dr. has a doctor from a group of doctors who take over and see patients in the hospital. i do not like this idea. durning the 3 times i have had this hospital docs care for me none of them ever came into my room and polittely introduced themselves to me. they just started rattling off instructions. no introduction-no explanation for their regime of care–they were haughty and some bordered on rudeness. they last time when i was in i called me doctor and told him i wanted him to either come over to the hospital himself or straighten out the assigned doctor or i was leaving. i feel that i can not trust a doctor who is unable to use good patient /doctor relations. this could be a good system, but as it is it is terrible patient care.

    September 16, 2010 at 11:00 | Report abuse | Reply
    • Nicole24

      I agree with you whole heartedly, but the problem is there are too many patients to see and not enough doctors to do it. I've been on rounds where we had 58 patients to see before going down to the OR at 7am...that's a lot of labs/vitals/physical exams/medications to check on, and notes to write. I love talking to patients in the hospital, but there isn't always enough time. I sometimes think if patients were more aware of the problem with scheduling, and patient load, maybe they wouldn't feel so dismissed and be more understanding.

      September 16, 2010 at 16:10 | Report abuse |
  5. Bob

    I am a hospitalist for a community-based hospital in the northeast. It has a reputation for being a "country club" hospital. We take care of hedge fund managers and little old ladies. Many of the physicians working there have excellent ratings. I would not send my family to that hospital. I think the care was sub-par. I trained at a university hospital, a VA, and a private hospital. The hospital I work at now is filled with doctors who were probably smart at one time, but stopped reading and got lazy. I admit two types of patients: patients belonging to a "boutique practice" and patients with no listed primary care physician. We contract with the boutique practice docs. I am surprised that there are so many rich, well-educated patients who do not realize that these boutique docs practiced bad medicine. I was suprised how often the patients from the free clinic had excellent medical care. I remember a patient I admitted, who realized his hospitalization was due to a preventable complication from his expensive boutique doctor, asked me to refer him to the best primary care doctor I knew in the area. I said, "The patients I see from the free clinic seem to be on the right medicines, and seem to have received the appropriate workups more than most of the other patients I get from the boutique clinics. Unfortunately, you're too rich to go there." It is regrettable that no patient can really be an informed consumer when it comes to health care. Health care is so complex, that even people in the medical community might not know who is a good doctor and who isn't. Since I am an hospitalist/internist, I can figure out who is good at internal medicine. Even as a doctor, I don't know which of the surgeons I work with is the best, or which dermatologist is the best. I know which ones are professional, and which ones I like, but that is very arbitrary.
    I knew two cardiothoracic surgeons when I was in medical school. One only took low-risk patients, and the guy was a machine. He never made a mistake. His patients all did very well. The other surgeon took high-risk patients. He did amazing and beautiful surgery, but many of his patients had complications post-operatively. Who is a better doctor?

    September 16, 2010 at 12:48 | Report abuse | Reply
    • leonardo Dominguez

      You are totally true my friend....society has no common sense...., I cannot imagine being in a boutique.... with those money making MDs who select cases based on how easy they are, how well they pay, and then if you have a bad disease....they refer the patients to the University Docs have to take care......
      There is nothing fair in this world....

      April 27, 2011 at 19:34 | Report abuse |
  6. Bob

    Mabel, I know what you are saying. I am a hospitalist, one of those doctors you describe. Some hospitals (mine included) place patient satisfaction above good or efficient care. I disagree with this. I think patient health should be first, then patient satisfaction. Gone are the days of Dr. Kildare. As the science of medicine has evolved, so has its delivery. Many outpatient doctors can't efficiently and appropriately care for their inpatients while running a full clinic, as inpatient medicine now often requires constant attention. 50 years ago, you had nice doctors who would spend 3 hours interviewing and examining you for a heart attack. They would know all about your personal life and family. Then they would give you morphine for your heart attack and hope you lived. As a physician and a patient, i would rather have an efficient, excellent doctor over a warm, friendly, incompetent physician. Most patients can't tell who's good and who's bad, but they can identify who's nice and who's a jerk. The jerks are the ones who get sued, not the ones who are incompetent. However, I think it's not too hard to be both nice and competent. I'd like to think that I am both ;)

    September 16, 2010 at 13:05 | Report abuse | Reply
    • John

      I agree. Do the right thing and help the patient understand why it is the best way. Too many doctors and hospitals have changed the hypocratic oath to I will not do harm to my bottom line.

      September 16, 2010 at 15:53 | Report abuse |
    • MikefromWV

      Last night I had to give in and go by ambulance to the ER at our local hospital, with chest pain so severe I believed I was having a heart attack. Fortunately, in one sense, it was only bacterial pneumonia. I tried like heck to resist going, because this hospital has left me with a strong sour taste in my mouth. They promote like heck their excellent patient ratings and patient care, when just the opposite is true. They tout their accreditation loudly, but anyone who has had dealings with them, know that they get word in advance of an upcoming accreditation evaluation. They will run around like crazy getting their paperwork all in order and ensuring that all protocols and policies are in line. Then, after the evaluation is over, the place goes to heck all over again. Infectious disease protocols are largely ignored. Same with basic safety protocols. The staff is overworked and underpaid and the food is terrible. Anyone in the know who has a serious problem tries to go the University Hospital in Morgantown. They have a better chance of survival by doing so.

      And the doctors, by in large, are aware of the problems and just ignore them. Many of the doctors have a terrible bedside manner and treat their patients like sh**.

      And there are definitely separate, distinct levels of care, based on what your insurance status is. The highest level of care goes to those with insurer's like BC/BS. The next level of care, downward, is to those who have Medicare. The next step down is to those who have Medicaid. And the final downward step is to those who have no insurance.

      September 16, 2010 at 17:49 | Report abuse |
    • Joel

      Bob,

      I'm interested to know your thoughts on the use of nurse practitioners in the hospital and outpatient setting and how it affects the quality of patient care, as well as patient satisfaction. Have you noticed any differences? What about NPs who work in conjunction with MDs?

      September 16, 2010 at 18:00 | Report abuse |
  7. Jackie

    As a patient with a long-term, chronic illness, I find that the major problem I encounter with my doctors has almost nothing to do with how good they are individually as doctors, but rather with how different specialists fail to work together to care for a patient. Even though I go to a well-respected clinic which employs doctors of most specialties, all of whom have access to my records from all of the others, each doctor is concerned only with his own specialty. There is no 'team' approach; none of them know or care what the others are doing. Theoretically, my primary care physician would be in a position to play the role of 'care coordinator', but in actual practice these days primary care doctors act only as 'acute care' doctors. If you have a sprained ankle or a sore throat or a kid with an ear infection, they're great. Otherwise, they just 'refer you away'. To be honest, they don't have TIME to do anything else; the number of patients they are expected to see in day in a typical 'group practice' setting is almost unbelievable. In my opinion two specialties that don't commonly exist, but should, are 'diagnostics' and 'chronic disease management' or 'care coordinator'. Patients would get better care and would not be so frustrated, trying to figure out which doctors to see for what, particularly when the cause of a particular symptom is unclear.

    September 16, 2010 at 13:12 | Report abuse | Reply
    • MikefromWV

      I also am one with many, chronic, long-term health issues. The biggest problem that I see with a "team" approach to treatment is that in most instances, the patient is not on the "team". The "team" will meet and discuss patient issues and problems and come to conclusions without ever bringing the patient onboard to hear out their concerns with any potential solutions. You see this most prevalently at the larger, university style, teaching hospitals, where you may not even meet your primary physician, but, more likely, will be 'handled' by interns. Even more worrying is when you have to have a surgical procedure done and end up not being operated on by the doctor in charge of your case.

      September 16, 2010 at 17:57 | Report abuse |
  8. wingri

    I am a practicing physician at a large academic medical center. I agree that the current measures of clinician quality fall short. They judge specific measurable processes that have been associated with better outcomes. The doc who makes sure they adhere to these processes will score well. Unfortunately, the doc who is focused on checking all the right boxes, may not actually address what is most important for that particular patient before him/her. Until real risk adjusted outcomes are used to measure quality, I doubt the measures will mean much. Even then, we'll have to take them with a big grain of salt as risk adjustment is a tricky businesss.

    September 16, 2010 at 13:14 | Report abuse | Reply
  9. nomoregbldgk

    ...a disincentive to being a lousy doctor.

    September 16, 2010 at 13:19 | Report abuse | Reply
  10. altheajj

    An excellent diagnostician with compassion. I believe that makes a good doctor. And I am fortunate enough to have one as my primary care physician.

    September 16, 2010 at 13:56 | Report abuse | Reply
  11. David

    I have suffered with Crohn's Disease all my life (I am over 50). I have been through over 15 GI doctors in my life. Don't stay with a doctor when they start doing things by rote. Any doctor can write a prescription and, some cases that's all they can do.

    A patient with critical needs also must keep up to date with medical news about their disease. A smart patient will usually find a smart doctor.

    September 16, 2010 at 14:08 | Report abuse | Reply
  12. May Voirrey

    A good doctor is compassionate. Up-to-date on research findings and treatments in his or her are of specialization. Listens more and talks less. Pays attention. Is not rude, arrogant, condescending, or dismissive. Is able to put personal prejudice aside. Is willing to admit it when he or she does not know something. Has a sincere desire to actually help the patient. Embraces professional development. Understands that patients might also know a thing or two. Accepts that attention and effort beyond the quick, obvious fix mght be required.

    September 16, 2010 at 14:11 | Report abuse | Reply
  13. Deb

    It is summed up in the comment "Has a sincere desire to actually help the patient." I suffered from horrible joint pain for 15 years, doctor after doctor just wanted to write a script or run a couple tests. What good where the tests if you where not going to use them to figure out the cause of the pain. The test was negative....OK? What next? Referral of course...I'm not going to bother looking any further, I got my $250 bucks and your 10 minutes is up.

    After 15 years I did find a doctor who promised she wouldn't give up, she promised she wouldn't give me a perscription just to push me out the door, she promised that even if the insurance company didn't like the tests she did she would find the cause of the pain. Two office visits later and a positive blood test for a wheat allergy and the pain is gone.

    Over 15 years I saw about 20 different doctors who don't even deserve that title. They didn't care about me or the pain I suffered. They cared about the paycheck they took home on my behalf.

    September 16, 2010 at 14:39 | Report abuse | Reply
  14. Tom

    sringangel, you've missed the point. Underserved populations tend to place a lower priority on health than other things (like figuring out where they're going to sleep tonight, or if/how they're going to find their next meal).. And they may or may not have transportation, a stable address or telephone number, and probably can't plan more than a few hours into the future. So report cards that judges doctors by results–which would normally make sense–have to take into account that a lot of "results" are WAY beyond a doctor's control.

    September 16, 2010 at 14:44 | Report abuse | Reply
  15. Fuyuko

    I like doctors who will listen and be polite. It is hard for patients to talk about their symptoms. The last doctor I saw was so rude, he made a joke about what I was wearing, didn't believe me when I told him I had a reaction to medicine, and in general acted like an egotistical jerk. He was a good doctor and the advice I got was good. But the attitude made me not want to return. Plus he seemed overly caffeinated. He was busy and I was't worth his time- was the impression I got.

    September 16, 2010 at 16:19 | Report abuse | Reply
  16. Dr. Mama

    This is a complicated question. Most doctors, though not all, are perfectionists who take great pride in the high technical quality of their work. Does that make them "good doctors"? Not if they fall down in their relationships with patients, because we know that connecting with patients is a critically important aspect of physician effectiveness.

    This may also be part of the reason why doctors in underserved, urban areas get lower marks than those in more affluent neighborhoods. It's easier to form a relationship with patients who are more like us - in income, education and life experience - than it is with those who's lives we're less familiar with. Add to that the typical increased patient loads in these areas and you can see how the problem could expand.

    A "good doctor" is well-trained, meticulous, AND engaged with his/her patients. All are equally important.

    And, by the way, I'm a pediatrician no longer in clinical practice.

    http://mamasoncall.com

    September 16, 2010 at 16:41 | Report abuse | Reply
  17. dew

    My body decided to mutiny a number of years ago and I was thrust into the nightmare of uncaring doctors and ignorant office staff. Most doctors I've seen seem to lack compassion, yes, but even further, they lack listening skills. They simply will not listen to the patient tell their story and how they're feeling. I have a long and complicated history and I can never explain all of it because they're in too big of a hurry to get to the next patient. My guess as to the reason that doctors who care for underinsured and poor patients receive poorer scores than their counterparts who care for insured, richer patients is that the poorer patients are going to go to the doctor less, eat a less healthy diet and will generally not care for themselves as well as a patient with financial means, and health issues accumulate because of it. The underserved patient's poorer health coupled with a doctor who is trying to move through as many patients a day as possible and doesn't have time to sit and listen results in poorer care for the patient.

    When doctors realize that regardless of their number of years of education, we have lived in our bodies far longer and we know when something is wrong, and stop blowing us off for fear of admitting they don't immediately know what's wrong but saying they will keep looking, (and that goes for doctors learning to listen to a mother's instinct when there is something wrong with their child) then we will see patients learn to trust their doctors, follow their doctor's instructions and return for follow up visits. Patients will then know that their doctor is on their side and the two can work as a team. As it is now, most people seem to be fed up with egotistic god-complex that is a huge portion of our "health care" system. And really, it's more of a 5-minute, $85. infomercial for the pharmaceutical companies rather than learning how to be healthy people.

    September 16, 2010 at 17:11 | Report abuse | Reply
  18. kleentx

    I agree with the posters who said compassion from your doctor is the most important factor. When we moved to a new city several years ago, I needed a good gyno and knew no one. I asked around and was referred to Dr. P. My first visit was the usual – vital signs, description of my problem, prescription. However, when I began the prescription is caused me to start bleeding excessively and I could do nothing to stop it. I called the office and was immediately taken in and seen. Over the course of 2 months, this continued and he saw me each and every time I was forced to "drop in." The best part of all was when he gave me his personal telephone number and told me to call him anytime. I ended up having a hysterectomy that he performed. Afterward, he not only explained why along with the results of the pathology tests, but also informed me of why I had to have 2 C-sections 12 years earlier which had never been explained to me by either of my obstetricians. Dr. P is the sweetest, most compassionate physician I have ever met and I have seen quite a few in my 50+ years and 12 surgeries.

    September 16, 2010 at 17:13 | Report abuse | Reply
  19. Dr Bill Toth

    Being a doctor is the world's greatest profession, and a less than great business. Being a great doctor means doing the best you can with the resources you have, knowing that one is merely a coach and a vessel because healing only comes from within. Live with Intention, DrBillToth.com/blog

    September 17, 2010 at 07:22 | Report abuse | Reply
  20. Diane

    Replace "doctor" with "teacher" and "Patient" with "student" in this article and the point would be the same. We try to develop rating systems for complex things (healthcare and education), we don't take into account the patient/student's own motivation to change, their home life, family, ability to do what the doctor/teacher wants, etc. We end up with systems that make the doctors/teachers who work in poor environments look like they're all 'bad' while those who work with wealthier, motivated patients/students are all 'good.'

    September 17, 2010 at 11:49 | Report abuse | Reply
  21. Kevin

    I agree – it is difficult to measure factors that determine if a doctor is "good" or "bad".
    There are many soft qualitative skills (listening, compassion, etc) that rank high in importance to patients that are difficult to quantify and measure. Report cards that only include factors that are more quantifiable skew results and should be referred to with caution. Patients should use a variety of sources to decide on their doctor, not just report card scores.

    http://www.caring-for-aging-parents.com

    September 20, 2010 at 21:33 | Report abuse | Reply
  22. Sherril A Quinn

    You make very valid point indeed! The bias you face is very similar to the bias faced with our educational system i am sure. Both students & teachers in low-socioeconomic areas deal not only with a plethera of social ills, but diverse languages and culturesmas well. Making a wide sweeping grading system flawed and basically irrelevant.
    Sorry to read that the current system is creatin a misconception of physician who are doing what so many would not. Teachers too feel the dis-heartening results of these biased rankings. Obviously created by those with no experience in the true trenches of America.
    Keep your chin up, there are those who value your work!!

    August 6, 2011 at 15:57 | Report abuse | Reply
  23. Adult Fish Dating

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    April 10, 2012 at 17:27 | Report abuse | Reply

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